Urogenital Atrophy

Alternative and non-hormonal treatments to symptoms of menopause

Ovarian function can start to decline a few years before the eventual cessation of the menstrual cycle. The average age of menopause in the UK is 51 years, and it is a retrospective diagnosis after 12 months of amenorrhoea. Women can experience many symptoms such as vasomotor and vulvovaginal symptoms that impact them physically, psychologically, sexually and thus their overall wellbeing. Women may have medical contraindications to hormonal therapy or may prefer non-hormonal or alternative treatments. This review looks at the evidence, efficacy, and safety of a range of complementary or alternative treatments and non-hormonal pharmacological treatments for the treatment of vasomotor symptoms and vulvovaginal atrophy of menopause.

Vulvovaginal atrophy

Vulvovaginal atrophy (VVA) is a common and underreported condition associated with decreased estrogenization of the vaginal tissue. Symptoms include dryness, irritation, soreness, and dyspareunia with urinary frequency, urgency, and urge incontinence. It can occur at any time in a woman's life cycle, although more commonly in the postmenopausal phase, during which the prevalence is close to 50%. Clinical findings include the presence of pale and dry vulvovaginal mucosa with petechiae. Vaginal rugae disappear, and the cervix may become flush with the vaginal wall. A vaginal pH of 4.6 or more supports the diagnosis of VVA. Even while taking systemic estrogen, 10% to 20% of women may still have residual VVA symptoms. Breast cancer treatment increases the prevalence of VVA because the surgical, endocrine, and chemotherapeutic agents used in its treatment can cause or exacerbate VVA. Local estrogen treatment for this group of women remains controversial.

Expression of vascular endothelial growth factor in the lower urinary tract in rats after castration and estrogen administration

OBJECTIVE

To evaluate quantitatively, by means of immune histochemistry, the expression of the vascular endothelial growth factor (VEGF) in the bladder, vesicourethral junction, and urethra in normal, castrated adult rats and under estrogen administration.

DESIGN

Sixty adult virgin rats (Rattus norvergicus albinus, Rodentia, Mammalia) from the CEDEME-UNIFESP Animal House were used. Rats were divided into three groups. Group I comprised noncastrated rats, group II comprised oophorectomized rats, and group III comprised castrated rats administered 17beta-estradiol in the form of subcutaneous implants at the dose of 0.18 mg/implant for 30 days. After performing standard immunohistochemistry procedures, the intensity of the dark-brown color was used as the cytoplasmic protein expression of VEGF. Cells without this coloration or weakly stained were considered negative. percentile of VEGF expression was obtained by counting 1,000 cells per slide and establishing the ratio between positive and total cells.

RESULTS

The VEGF expression was uniform and similar along the urinary tract in group I. After castration, protein expression was almost absent in the bladder and was low in the vesicourethral junction and urethra. With estrogen replacement, very little of the expression was recovered in the bladder, and the reaction became evident in the vesicourethral junction and urethral sections.

CONCLUSIONS

The present study implies a potential relationship between VEGF and urinary tract physiology. The results suggest that there are quantitative differences in VEGF expression in these tissues depending on steroid hormone status.

The evolution of aging: a new approach to an old problem of biology

Most gerontologists believe aging did not evolve, is accidental, and is unrelated to development. The opposite viewpoint is most likely correct. Genetic drift occurs in finite populations and leads to homozygosity in multiple-alleled traits. Episodic selection events will alter random drift towards homozygosity in alleles that increase fitness with respect to the selection event. Aging increases population turnover, which accelerates the benefit of genetic drift. This advantage of aging led to the evolution of aging systems (ASs). Periodic predation was the most prevalent episodic selection pressure in evolution. Effective defenses to predation that allow exceptionally long lifespans to evolve are shells, extreme intelligence, isolation, and flight. Without episodic predation, aging provides no advantage and aging systems will be deactivated to increase reproductive potential in unrestricted environments. The periodic advantage of aging led to the periodic evolution of aging systems. Newer aging systems co-opted and added to prior aging systems. Aging organisms should have one dominant, aging system that co-opts vestiges of earlier-evolved systems as well as vestiges of prior systems. In human evolution, aging systems chronologically emerged as follows: telomere shortening, mitochondrial aging, mutation accumulation, senescent gene expression (AS#4), targeted somatic tissue apoptotic-atrophy (AS#5), and female reproductive tissue apoptotic-atrophy (AS#6). During famine or drought, to avoid extinction, reproduction is curtailed and aging is slowed or somewhat reversed to postpone or reverse reproductive senescence. AS#4-AS#6 are gradual and reversible aging systems. The life-extending/rejuvenating effects of caloric restriction support the idea of aging reversibility. Development and aging are timed by the gradual loss of cytosine methylation in the genome. Methylated cytosines (5mC) inhibit gene transcription, and deoxyribonucleic acid (DNA) cleavage by restriction enzymes. Cleavage inhibition prevents apoptosis, which requires DNA fragmentation. Free radicals catalyze the demethylation of 5mC while antioxidants catalyze the remethylation of cytosine by altering the activity of DNA methyltransferases. Hormones act as either surrogate free radicals by stimulating the cyclic adenosine monophosphate (cAMP) pathway or as surrogate antioxidants through cyclic guanosine monophosphate (cGMP) pathway stimulation. Access to DNA containing 5mC inhibited developmental and aging genes and restriction sites is allowed by DNA helicase strand separation. Tightly wound DNA does not allow this access. The DNA helicase generates free radicals during strand separation; hormones either amplify or counteract this effect. Caloric restriction slows or reverses the aging process by increasing melatonin levels, which suppresses reproductive and free radical hormones, while increasing antioxidant hormone levels. Cell apoptosis during CR leads to somatic wasting and a release of DNA, which increases bioavailable cGMP. The rapid aging diseases of progeria, the three diseases: (xeroderma pigmentosum (XP), Cockayne syndrome(CS), and ataxia telangiectasia (AT)), and Werner's syndrome are related to or caused by defects in three separate DNA helicases. The rapid aging diseases caused by mitochondrial malfunctions mirror those seen in XP, CS, and AT. Comparing these diseases allows for assignment of the different symptoms of aging to their respective aging systems. Follicle-stimulating hormone (FSH) demethylates the genes of AS#4, luteinizing hormone (LH) of AS#5, and estrogen of AS#6 while cortisol may act cooperatively with FSH and LH, and 5-alpha dihydrotestosterone (DHT) with FSH in these role. The Werner's DNA helicase links timing of the age of puberty, menopause, and maximum lifespan in one mechanism. Telomerase is under hormonal control. Most cancers likely result from malfunctions in the programmed apoptosis of AS#5 and AS#6. The Hayflick limit is reached primarily through loss of cytosine methylation of genes that inhibit replication. Men suffer the diseases of AS#4 at a higher rate than women who suffer from AS#5 more often. Adult mammal cloning suggests aging-related cellular demethylation, and thus aging, is reversible. This theory suggests that the protective effect of smoking and ibuprofen for Alzheimer's disease is caused through LH suppression.

Psychological and sexual aspects of the menopause and HRT

Despite the clinical impressions that there are considerable psychological benefits from HRT, there is only clear evidence for amelioration of psychological symptoms (including improvement in cognitive function) in women who have undergone a surgical menopause. Otherwise in the natural menopause it remains unclear which, if any, non-sexual psychological symptoms respond directly to oestrogen except as a secondary response to reduction in physical symptoms. Overall, it has to be said that there is little scientific backing for hormonal treatment of psychological problems on their own around the time of the natural menopause. In most cases psychological treatment or counselling will be more appropriate than HRT. It must be remembered that the prevalence of psychological symptoms in the menopause and gynaecology clinic is high just as it is in all hospital settings. The task is to identify which women: 1. Have a predominance of psychological symptoms and might have psychiatric disorders. They may have presented in the clinic because they also happen to be menopausal, but it may well be that the psychiatric disorder has a quite independent aetiology. They will benefit from specific treatment for that disorder. 2. Have, and complain of, low moods or other non-specific psychological symptoms and have presented in the clinic because they are menopausal. They might benefit from practical, supportive help with current and ongoing stresses and strains. 3. Present appropriate menopausal complaints and only on enquiry reveal their psychological problems. In particular, disorders such as depressive illness, anxiety states and alcohol abuse can present with physical symptoms including ones which mimic vasomotor ones. This group may well be non-responders to HRT. Women requiring particular consideration might be those with other health problems (particularly chronic ones that might carry on in to old age) who are possibly more at risk of developing depression as they pass through the menopause. There is clearer evidence that HRT has beneficial effects on sexual function. When sexual symptoms are presented it is worth clarifying the exact features contributing to the complaint. Is it a problem of sexual interest, of infrequency of sexual activity, of vaginal dryness and dyspareunia, or is it a mixture of these complaints? Reduction of sexual interest and reduced sexual activity with the partner and possibly orgasm may accompany the menopause. Oestrogens have been shown to have some beneficial effect on sexual desire. Where oestrogen alone is ineffective, testosterone is usually beneficial. This treatment effect is particularly clear in surgically menopausal women. Non-menopausal aspects of the sexual relationship must be considered too. These aspects include the quality of the relationship, the sexual performance of the partner (since sexual desire decreases in both sexes with age), and age-related changes in self-image. These issues may need to be addressed at a simple health education level or with specific counselling. Although a woman's motivation or desire might change as a result of HRT, on its own this will not influence the frequency of intercourse or response during intercourse unless the partner variables permit this. The situation is more straightforward when problems of postmenopausal vaginal dryness and dyspareunia are the key issues. Oestrogens have been shown to be highly effective in such circumstances. It is also worth noting that regular and continued sexual activity has been found to protect against vaginal dryness.

Gynecologic disorders in the older patient

This review addresses the presentation and management of gynecologic disorders in older women. While these conditions are often managed by a primary caregiver, many women may present to the ED because they lack a primary gynecologic caregiver, their established gynecologic caregiver is not available, they are embarrassed to discuss their symptoms with an established caregiver, or they seek immediate relief of symptoms and reassurance. The emergency physician (EP) must be aware of the normal physiologic changes that occur with aging and how these changes may produce symptoms in older women. This review addresses physiologic changes and pathophysiologic conditions. Knowledge of these conditions and their management will facilitate reassurance of the patient, expedite appropriate initial therapy, and enable the EP to efficiently refer patients requiring further gynecologic assessment.

Effects of pregnancy on urethral and bladder neck function

Pregnancy and menopause induce morphologic as well as functional changes in the female urethra. Symptoms of bladder irritation (frequency, urgency) and incontinence are frequent findings in these conditions and are considered to be due to alterations in the distribution of autonomic receptors induced by the changes in the hormonal milieu. In the present study, the functional responses to field stimulation (FS) and autonomic agonists of the bladder neck and urethra of pregnant, and virgin New Zealand White rabbits were compared using isolated muscle strips. Passive length-tension studies demonstrated a significantly greater compliance of strips (bladder neck and urethra) from pregnant rabbits than from virgin rabbits. FS elicited frequency dependent contractile responses in all strips. Phentolamine was significantly more effective at inhibiting the field stimulated contractile response of urethral strips from pregnant than from virgin rabbits. Atropine was significantly more effective at inhibiting the response to FS of strips isolated from bladder necks of virgin rabbits than in strips isolated from pregnant rabbits. Atropine was significantly less effective at inhibiting the response to FS of strips isolated from urethras of pregnant rabbits than of strips from virgin rabbits. Strips of bladder neck and urethra isolated from virgin rabbits responded with significantly greater contraction to phenylephrine than strips isolated from pregnant rabbits. The magnitude of field stimulated relaxation was significantly greater in urethral strips than in bladder neck strips, and also greater in urethral strips isolated from virgin rabbits than in strips isolated from pregnant rabbits. In conclusion, pregnancy induces profound hormonal changes which, in turn, result in the alteration of the compliance and functional responses of the bladder neck and urethra to various forms of autonomic stimulation and relaxation.